Will Medicaid Pay for Assisted Living in NC? A Guide to Coverage and Eligibility

Thinking about a new home for your adult child is a journey of both hope and worry. You dream of seeing them build a life of their own, but the practical questions, especially about the cost, can feel heavy and isolating. Navigating this path is a huge step, and it’s completely normal to feel uncertain as you explore what’s possible for their future.

The world of financial support is often filled with confusing terms like waivers and NC Medicaid eligibility rules. You just want a clear path forward. So, will Medicaid pay for assisted living in NC? While traditional Medicaid doesn’t cover room and board, North Carolina offers specific programs designed to help pay for the personal care and support services your adult child receives in an adult care home. Below we help you understand how these programs work.

Does Medicaid Cover Assisted Living in NC?

It helps to think of standard North Carolina Medicaid like health insurance. It’s designed to cover medical needs like doctor visits, therapies, and prescription medications. However, it typically does not pay for the monthly cost of room and board in a residential facility, such as an adult care home in NC or an assisted living community. This is a common point of confusion, but it doesn’t mean financial help isn’t available.

The solution often involves combining different state and federal programs to create a complete support plan. For families in North Carolina, the key is understanding how Medicaid Personal Care Services (PCS), the NC Innovations Waiver, and the State/County Special Assistance (SA) program can work together. Each program plays a different role in paying for the costs associated with assisted living.

Here’s a simple breakdown of how the pieces fit together:

• Medicaid Waivers and PCS for Care: Programs like the NC Innovations Waiver are designed to fund the actual support services a person needs to live more independently. This includes hands-on help with daily activities like bathing, dressing, medication management, and other personal care tasks. These services are brought into the residential setting to support your adult child.
• Special Assistance (SA) for Room and Board: The SA program is separate from Medicaid and is specifically designed to help eligible individuals pay for the cost of living in a licensed residential facility, like an adult care home. Think of this as the program that helps cover the rent and food.
• Finding the Right Facility: A crucial step is finding an adult care home that is licensed to accept SA payments and works with residents who use Medicaid waiver services. Not all facilities are set up this way, so asking this question upfront is essential.

In assisted living communities across the country, almost 1 in 5 residents (18%) relies on Medicaid to help pay for their daily services. This shows just how common and necessary these support programs are for many families.

North Carolina’s SA Program Explained 

The SA program is a North Carolina supplement that helps pay for lodging in licensed adult care homes, which includes many assisted living facilities. It is designed for low-income individuals who are either at least 65 years old or have been designated as disabled. Think of it as the program that helps cover the “rent” when your adult child’s own income isn’t enough.

Who Qualifies for Special Assistance?

Eligibility for the SA program is based on four key requirements. Your adult child must:

• Be a resident of North Carolina.
• Be age 65 or older, OR be determined to be disabled by the Social Security Administration.
• Meet strict income and asset limits. Similar to the rules for Supplemental Security Income (SSI), an individual generally cannot have more than $2,000 in countable assets.
• Be assessed by a professional and found to need the level of care that an adult care home provides.

What Does Special Assistance Cover?

The program provides a monthly cash payment that goes toward the cost of room and board at the facility. This payment helps bridge the gap between your adult child’s income and the facility’s state-approved rate. The final amount of assistance depends on their specific financial situation and the home they choose.

How to Apply for Special Assistance

Applications are managed by the Department of Social Services (DSS) in your local county. The process is designed to be straightforward.

1. Contact Your County DSS Office: This is the first step to get the application and a list of required documents.
2. Gather Your Information: You will need proof of identity, residency, income, and assets for your adult child.
3. Submit the Application: Complete and return the application to the DSS office. A caseworker will be assigned to review the information.
4. Complete the Assessment: A care needs assessment will be scheduled to confirm that the level of care provided by an adult care home is appropriate.

The Role of the NC Innovations Waiver

The NC Innovations Waiver is a special North Carolina Medicaid program designed for individuals with intellectual or developmental disabilities (IDD). Its main purpose is to provide the necessary support for individuals to live successfully in their community instead of in an institutional setting. While it doesn’t pay for room and board, it funds the services that make community living possible.

What Services Can It Fund in a Residential Setting?

In an adult care home or supported living apartment, the waiver can fund a variety of services tailored to your adult child’s needs, including:

• Community Living and Support (CLS): This provides one-on-one assistance with daily living tasks to help your adult child build independence at home and engage with their community.
• Supported Living: This service offers personalized support for individuals who want to live in their own home or apartment but need assistance with daily tasks and routines.
• Respite Care: This service offers short-term relief for primary caregivers, giving you time to rest while your adult child is in trusted care.
• Day and Employment Supports: The waiver can fund participation in day programs or supported employment services that foster a sense of purpose and community connection.

An Important Note on Waitlists

It’s important to know that the NC Innovations Waiver has a significant waiting list, officially known as the Registry of Unmet Needs. Because accessing these services can take time, it is important to get on the waiting list as early as you can.

A Clearer Road Ahead

Figuring out how to pay for assisted living in North Carolina can feel like a maze. The key is knowing that you can often pair different programs together, using options like the NC Innovations Waiver for hands-on care and the Special Assistance program to help with housing costs.

Just by learning about these options, you are taking a powerful step toward building a secure and purposeful future for your adult child. You are their best advocate, but help is available to guide you through the process.

If you have questions about which facilities in NC accept Medicaid programs, please reach out. A simple conversation can provide the clarity and confidence you need to move forward.